Nokea
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
- A. Elevate the client's right arm on pillows
- B. Place the client's right arm in a dependent sling
- C. Keep the client's right arm on the bed beside her
- D. Place the client's right arm across her body
Correct Answer: A
Rationale: Elevating the arm on pillows reduces edema and promotes lymphatic drainage post-mastectomy, aiding recovery.
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The physician has ordered Pentam (pentamidine) IV for a client with pneumocystis carinii. While receiving the medication, the nurse should carefully monitor the client's:
- A. Blood pressure
- B. Temperature
- C. Heart rate
- D. Respirations
Correct Answer: A
Rationale: Pentamidine can cause hypotension, so blood pressure monitoring is critical during administration.
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?
- A. Increase humidification, and suction the tracheostomy tube.
- B. Notify the physician.
- C. Sit the client upright, and encourage the client to breathe deeply and cough.
- D. Gently irrigate and suction the tracheostomy tube.
Correct Answer: A
Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (A). Notifying the physician (B) or encouraging coughing (C) is secondary, and irrigation (D) is not typically the initial step.
The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
- A. The client with HIV
- B. The client with a radium implant for cervical cancer
- C. The client with RSV (respiratory syncytial virus)
- D. The client with cytomegalovirus
Correct Answer: C
Rationale: The client with RSV poses the least risk to a pregnant nurse, as it is a common respiratory virus, whereas HIV, radium implants, and cytomegalovirus carry higher risks during pregnancy.
A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?
- A. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock
- B. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries
- C. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries
- D. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage
Correct Answer: C
Rationale: The ABCs of trauma care prioritize airway, breathing, and circulation. Establishing an airway comes first, followed by controlling hemorrhage and preventing shock, then assessing for head injuries.